Black Americans still get far fewer operations, tests, medications and other life-saving treatments than whites, despite years of efforts to erase racial disparities in health care and help African Americans live equally long and healthy lives, according to three major studies being published today.
Blacks' health care has started to catch up to whites' in some ways, but blacks remain much less likely to undergo heart bypasses, appendectomies and other common procedures. They receive fewer mammograms and basic tests and drugs for heart disease and diabetes, and they have fallen even further behind whites in controlling those two major killers, according to the first attempts to measure the last decade's efforts to improve equality of care.
Together, the research paints a discouraging picture of the nation's progress in closing the gap for one of the fundamental factors that affect well-being -- health care -- during a period when blacks have made progress in areas such as income and education.
"We have known for 20 years that we have a problem in our health care system: that blacks and whites do not receive equal care. We had hoped all the attention paid to this topic would result in some improvement. What we found is we have not made much progress," said Ashish K. Jha of the Harvard School of Public Health, who led one of the studies published in the New England Journal of Medicine. "This should be a call to action to make the changes needed to make sure people get equal care."
Despite the sobering findings, experts said they were encouraged that some care did improve for blacks when the government put pressure on health plans and doctors by requiring them to report whether they were meeting certain minimum standards.
Past studies have found that blacks and other racial minorities are much less likely than whites to receive many types of medical care. They are significantly more prone to illness, tend to experience more complications and take longer to recover when they get sick. They are more likely to succumb to their illnesses and generally die younger. Major medical organizations; local, state and federal health agencies; and private foundations have focused more on the problem in the past decade, launching a host of studies, programs and initiatives to try to close the gap.
In evaluating those efforts, the new studies examined only blacks, because reliable national data were unavailable for other minorities.
"These persistent disparities are saying that systematically, based on an individual's skin color, Americans are still treated very differently by our health care system," said David Williams of the University of Michigan at Ann Arbor. "This is clearly unacceptable, given the values of our society. It's wrong both on a moral dimension and on a very practical dimension of ensuring life and the pursuit of happiness."
The cause of the persistent disparities has been the focus of intense research and debate. Blacks and other minorities tend to be poorer and less educated, which accounts for some of the differences. Some experts argue that blacks also tend to live in places where doctors and hospitals provide inferior care. Others suspect that cultural, or even biological, differences may also play a role. The most intense debate has centered on whether subtle racism pervades the health care system.
"There are clearly large gaps in the quality and quantity of care of African Americans relative to whites. But these papers cannot be used to argue that this is a result of discrimination," said Amitabh Chandra of Harvard University. "It could be that whites are getting way too much care than they should be getting."
The only hint of a cause offered by the new studies was the finding that gains tended to occur for the simplest care -- such as prescribing drugs -- and gaps tended to widen for more complex treatment.
In the first study, Jha and his colleagues analyzed data collected on all 30 million patients enrolled in Medicare each year from 1992 to 2001, examining how often they got nine of the most common surgical procedures.
By 2001, the researchers found, the gap between whites and blacks had narrowed only for one operation for each sex: the repair of abdominal aortic aneurysm among men and angioplasties for women -- a disparity that disappeared entirely. But the gap failed to narrow for heart bypasses and valve replacements, and it increased for back surgeries, stroke-preventing procedures called carotid endarterectomies, hip replacements, knee replacements and appendectomies.
"These are procedures that have significant consequences on peoples' well-being and lives," Jha said. "The fact that blacks receive significantly fewer of these procedures is having a significant impact on their quality of life and longevity of black Americans."
When the researchers examined whether the gaps had narrowed in particular regions, they found that no place had significantly equalized care for blacks for three procedures: bypass surgery, endarterectomy and hip replacement. In the Washington area, the gap widened slightly for all three, with blacks on average 50 to 70 percent less likely to get the operations.
"The size of the differences between whites and blacks is really distressing, and the fact that we see no progress happening anywhere across the country is really distressing," Jha said.
In the second study, Viola Vaccarino of Emory University and colleagues studied the records of 598,911 patients treated for heart attacks at 658 hospitals from 1994 to 2002. Blacks remained much less likely than whites to get basic diagnostic tests known as angiographies, as well as drugs or procedures to reopen clogged arteries, such as angioplasties. Women were also less likely to get appropriate care than men, with black women receiving the worst care of any group, the researchers found.
In the third study, Amal N. Trivedi of Harvard Medical School and colleagues analyzed data on 1.5 million Medicare patients in 183 managed care plans from 1997 to 2003, examining whether women had mammograms, and whether heart disease and diabetes patients got basic tests and treatments.
The quality of care overall improved significantly for both blacks and whites, with blacks narrowing the gap with whites on seven of nine measures; on five measures, the difference fell to less than two percentage points. But the gap failed to disappear entirely in any category and widened for two, with fewer diabetic blacks having their blood sugar controlled properly and fewer black heart patients lowering their cholesterol.
"There's no measure where the performance for blacks is higher than for whites or even equal," Trivedi said. "Clearly, there's a lot more work that needs to be done."